Things We Do For No Reason: Lactate, Cocaine, Falls, and Discharge Timing

Lactate as a Biomarker

• 💡 Lactate elevation is often mistakenly equated with tissue hypoperfusion or hypoxemia, but it's frequently due to other factors like beta-2 activation.
• 🔬 In conditions like sepsis or shock, increased epinephrine leads to beta-2 activation, causing pyruvate overproduction and thus elevated lactate, rather than solely a lack of oxygen.
• ⚠️ Hypoxemia itself, even at high altitudes like Everest, does not always result in significantly elevated lactate levels, challenging the direct link.
• 🩺 Lactate is a non-specific biomarker and should not be the sole basis for decisions like aggressive fluid resuscitation; a thorough clinical assessment is crucial.

Beta Blockers and Cocaine Use

• 🧠 The concern about avoiding beta blockers in patients with cocaine use stems from a flawed 1990 study involving direct coronary artery injection of propranolol.
• 🚫 Newer, larger cohort studies and a follow-up study using IV labetalol suggest that beta blockers are safe in patients with a history of cocaine use, especially when indicated for conditions like heart failure or CAD.
• ✅ The benefits of beta blockers for established indications likely outweigh the theoretical risks associated with non-intracoronary cocaine use.

Anticoagulation and Fall Risk

• ⚖️ While patients with a history of falls are more likely to fall again, the data on whether this significantly increases the risk of intracranial hemorrhage (ICH) while on anticoagulation is not definitive.
• 📈 Bleeding scores should be used to identify opportunities for risk mitigation, such as treating alcohol use disorder or deprescribing certain medications, rather than as a sole reason to withhold anticoagulation.
• 🧠 Newer stroke risk scores like Garfield AF and Aetria may provide a more nuanced assessment of ischemic stroke risk than CHADS-VASc alone, potentially altering the decision-making calculus for anticoagulation.
• 💊 Dose reduction of DOACs is based on age, weight, and creatinine, not on fall risk.

Discharge Before Noon

• ⏰ The goal of